HOW HOSPICE WORKS:
THE PHYSICIAN-HOSPICE RELATIONSHIP

You are probably used to visiting your physician and then getting your medical advice directly from that physician. However, when the attending physician1 refers a patient to a hospice, the hospice assumes responsibility for providing care to the patient based on a Plan of Care which is under the supervision of the attending physician. This means that the patient will not regularly be seen by the physician, but rather by trained hospice staff who work with the physician. The hospice team (the "Interdisciplinary Team") meets regularly to create and update the Plan of Care. 2 The RN casemanager then contacts the physician who either approves or modifies the Plan of Care. Although all care is technically under the supervision or "orders" of the physician, the hospice is basically making most of the decisions regarding how often hospice staff will visit the patient. These decisions are based upon the "assessment" or "evaluation" of the situation by the RN, social workers and other hospice staff, including the hospice's own Medical Director.

Because the types of symptoms that arise due a particular terminal illness are similar from one patient to another, physicians have learned that standard protocols are effective and appropriate for the treatment of these symptoms. Each hospice, in conjunction with a team of physicians, creates a list of standard medications which may be used under certain specific situations, without calling the attending physician each time. These medication orders are called "standing orders." Each attending physician, who utilizes a hospice's services, pre-approves the "standing orders" of the hospice. In the event that the attending physician does not agree to all of the standing orders used by a hospice, then he or she may exclude certain medications and order that these medications cannot be used for his patients without directly contacting him or her for an order. (See "Understanding Standing Orders in Hospice - Section 6j).

An RN, or an LPN who is under the RN's supervision, may start giving routine medications listed on the standing order sheet without calling the physician for a new order each time. The physician is notified that the patient was started on a specific medication "per standing orders" and the physician later officially signs the order for that medication. In this way, the hospice relieves the physician of numerous and frequent calls at all hours of the day and night. However, if there is any question about the efficacy of a standing order medication, or if no standing order fits the patient's situation, the hospice nursing staff call the physician for specific orders.

Years ago, a family could expect the physician to visit the patient at home, especially when the patient was having severe symptoms. Today, the hospice staff are with the patient, either at home or in a facility, and the staff act as the "eyes and ears" of the physician, reporting signs and symptoms to the physician. Nowadays, many physicians do not generally make visits to the patient. The hospice staff contact the physician at regular intervals and as needed for updates, and the physician then gives his or her orders for the patient's care. If the hospice's Medical Director is physically visiting and examining the patient, either at home or in a facility, that is an indication of superior hospice care.

1 The "Attending Physician" according to 42 CFR 418.3 is the physician identified by the patient "as having the most significant role in the determination and delivery of the individual's medical care." If you have more than one physician, you must choose one of them to "take charge" of the care you will be receiving and who is willing to give the medical "orders" for all medications, services and equipment you may need. If you are seeing a specialist who has been treating you for the terminal illness, that specialist may be willing to assume the role of the attending physician for you. If not, your "family" doctor or the hospice's own medical director may assume this role, if you cannot find another physician to be the "attending physician."

2 The Hospice's Plan of Care for each patient must meet the standards set at 42 CFR 418.58. The plan of care must be adequate to meet the patient's needs and is to be reviewed by the attending physician, the hospice's medical director and all the members of the Interdisciplinary Team who are together responsible for establishing the plan of care.